Broker Application

GENERAL INFORMATION

All Fields Required
Name of Agency *

Mailing address *

Street address (if different)

City, State Zip *
,  
County *


Phone # *

Fax # *

Tax ID # *


Corporation
LLC
Partnership
Sole Proprietor

Volume of business brokeraged to wholesalers *
$ P&C
$ Auto

Products you wish to access
 Transportation
 Property
 General Liability
 Workers Compensation
 Umbrella
 Small Business Unit (SBU)
How Did You Hear About Us?



CONTACT INFORMATION

Agency Principal *

E-mail Address *


Transportation Contact *

E-mail Address *


P & C Contact *

E-mail Address *


Accounting Contact *

E-mail Address *



LICENSING INFORMATION - COMPLETE ALL THAT APPLY *

How many states are you licensed in? *


THE FOLLOWING DOCUMENTS ARE REQUIRED IF APPROVED

1. A copy of your E & O Declarations page
2. A copy of licenses from the states your agency is licensed to write business (agency and individual licenses are required)
3. A signed brokerage agreement (will be provided upon approval)

        

Interstate Insurance Management
2307 Menoher Blvd., Johnstown, PA 15905
Call: 814-255-7878
Fax: 814-255-6010
1-800-452-0297

Interstate Insurance Management is a series of RSG Underwriting Managers, LLC. RSG Underwriting Managers is a Delaware Series limited
liability company and a subsidiary of Ryan Specialty Group, LLC. In California: RSG Insurance Services, LLC License # 0E50879
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